1A

e
x

1B

2A

FOR OFFICE USE ONLY

Taxi Test Score:

City of Houston
Regulatory Affairs Division
1002 Washington Ave.
Houston, Texas 77002
Phone: 832.394.8803 Fax 832.395.9632

1)

____________________________

2)

____________________________

3)

____________________________

VEHICLE-FOR-HIRE
DRIVERS LICENSE APPLICATION
For which type of City issued drivers license do you want to apply? (Check one)
Charter

Taxicab

Limousine

Jitney

School Bus

Low Speed Shuttle

Pedicab

TNC

Name: Last: __________________________________ First: _________________________________ MI: _____________

Social Security Number: ______________________________ Place of Birth: _____________________________________
Mailing Address: ___________________________________________________ City: _______________ Zip Code: _______
Physical Address: _____________________________________________ City: __________________ Zip Code: _________
Phone Number:_____/______/_______ Alternate Number: _____/_ _____/_______ Email: _____________________________
Texas Drivers License Number: _______________________________ Class: ______ Expiration Date: _________________
Drivers License Restrictions (if any): __________________________________________________________________
Height: ____________________ Weight: ______________ Hair Color: ____________________ Eye Color: ____________
Date of Birth: _________/_________/_________ Sex: _____________ Race: ______________ Marital Status: __________

Please check one:

Have you previously had a city issued drivers license?

Yes

No

Do you currently have a city issued drivers license?

Yes

No

Have you had a city license suspended, revoked or denied?

Yes

No

Have you had a state issued drivers license denied, revoked or suspended?

Yes

No

Have you had any traffic violations in the preceding 12-months?

Yes

No

Have you ever been convicted of a crime?

Yes

No

UBER
What company do you intend to drive for? __________________________________________________________
List your occupation(s) and company name(s) for the past 5-years below:
DATE

NAME OF COMPANY

ADDRESS

OCCUPATION

List your places of residence for the past 5-years below:

NUMBER

STREET NAME

CITY/ STATE

ZIP

10/2014

2B

SCHEDULE M
Vehicle-For-Hire Drivers
Medical Examination Form
Name: _______________________________________________ Address: ___________________________________________
Please circle if you have ever had:

Heart Trouble

Epilepsy

Fainting Spells

Diabetes

Tuberculosis

If you have circled any of the above, please explain on the line below:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
To Be Completed by Physician:
Visual Acuity * (If individual wears glasses, test and record acuity with and without glasses)
Without Glasses: R 20/________ L 20/________ B 20/________

With Glasses: R 20/_________ L 20/________ B 20/_________

Field of Vision_______________________ Degrees__________________ Depth Perception_________________________________

Color Perception______________________________ Muscular Abnormalities____________________________________________
Hearing without Hearing Aid: Right_____________________________ Left ______________________________________________
Heart Sounds: At Apex Murmur _________________________ At Base Murmur__________________________________________
Rhythm_______________________________________________

Enlargement Indicated_______________________________

Pulse: Rate _________________________________________

Regularity ___________________________________________

Blood Pressure: Systolic ____________________________

Diastolic ________________________________________________

Condition of Arteries: Sclerosis ____________________________

Lungs: Rate ______________________________________

Pulsations _________________________________________
Breathing Sounds _________________________________________

Weight: _______________________________________________

Height:____________________________________________

Extremities: Deformities___________________________________________________________________________________________
Routine Office Urinalysis_________________________________________________________________________________________
Evidence of Infectious Disease, Mental Disability, Emotional Instability, or Drug Addiction: ________________________________
______________________________________________________________________________________________________________
Remarks regarding any Condition not within Normal Limits: _____________________________________________________________
______________________________________________________________________________________________________________

This is to Certify that I have examined: ____________________________________________________________ and

certify that he/she is mentally and physically fit to safely operate and drive a Vehicle-For-Hire.
Signature of Physician: ____________________________________________
*Please sign with M.D. or D.O. after your name**

Office Address Stamp

Date of Examination: _________________________________________________

Address: ___________________________________________________________
Telephone Number: _____________/______________/______________________

*Either a licensed physician or a licensed optometrist may perform visual Examination.

If additional space is needed, attach extra sheet.

****Physician MUST print title clearly after signature. MD/DO ONLY!****

** Note: Physical form mustText
be signed by an M.D. or a D.O. **

** The form must also be dated, have the clinics address and phone number, or it will not be accepted. **

1
10/2014

2C

City of Houston
Administration and Regulatory Affairs Department
Regulatory Affairs Division
Applicant Declaration
Declaration of Applicant:
My name is _________________________________________________________________ (first, middle and last name),
my

date

of

birth

is

_______________________________________________

and

my

address

is

__________________________________________________________________(street, city, state and zip code) and

USA
__________________country.
I have personal knowledge of the statements made in the application. None of the statements are misleading or false. I
acknowledge that issuance of the license, permit or certificate does not excuse or approve any violation of deed restrictions or
city, state or federal laws or regulations. To the extent that this declaration is made on behalf of a corporation or any other
legal entity or persons, I certify that I have fully advised them of the contents of the application and this declaration and that I
am authorized to execute this declaration.
I declare under penalty of perjury that the foregoing is true and correct.

Harris
Texas
Executed in _________________County,
State of ________________,
on the _____________ day of _____________
(month) _________________ (year).
________________________________
Applicant Signature

City of Houston Municipal Courts Department

1400 Lubbock St., Houston, Texas 77002 (Basement)
Warrant Check ($20.00 charge)
For Office Use Only
Applicant Information:

This certificate verifies that a database search for

City of Houston Class C Warrants ONLY
was performed on this date for the applicant declared on this form.

Name:

TX DL:

DOB:

Status: _________________________________

2
10/2014

2D

DEED RESTRICTION AND

LAW COMPLIANCE AFFIDAVIT
Please initial next to each paragraph:
_______I understand and agree that it is my responsibility to comply with all deed restrictions and city, state, and
federal laws, regulations and/or ordinances concerning any activity authorized by the license, permit, or certificate,
requested in the application to which this affidavit pertains and concerning any land or place where such activities
may be conducted.
_______I also understand and agree that the City of Houston by issuing the license, permit or certificate for which
I am applying does not excuse or approve of any violation of deed restrictions, of city, state or, federal laws,
regulations or ordinances and that the license, permit, or certificate will be void in the event that it is used in
violation thereof.
_______I fully understand that if the permit, license, or certificate for which I am applying is issued, the City of
Houston or any other appropriate entity may institute legal proceedings against me if I violate any deed restriction,
or any city, state or federal law, regulation or ordinance.
_______To the extent that this affidavit is made on behalf of a corporation or for the benefit of any persons other
than myself, I certify that I have fully advised them of the content of this affidavit and that I am duly authorized to
execute the same as the act and deed of the applicant or persons.
_______Failure to make timely payments on permit fees may lead to revocation of the permit.
_______Not Sufficient Funds (bounced checks will result in a $24.00 NSF charge and all future payments will be
required to be paid by money order or cashiers check.
_______Insurance policies allowed to lapse will be cause suspension/revocation of the permit.
My name is _________________________________________________________________ (first, middle and last name),
my

date

of

birth

is

_______________________________________________

and

my

address

is

__________________________________________________________________(street, city, state and zip code) and

USA
__________________country.
I acknowledge that issuance of the license, permit or certificate does not excuse or approve any violation of deed restrictions
or city, state or federal laws or regulations. To the extent that this declaration is made on behalf of a corporation or any other
legal entity or persons, I certify that I have fully advised them of the contents of the application and this declaration and that I
am authorized to execute this declaration.
I declare under penalty of perjury that the foregoing is true and correct.

Texas
Harris
Executed in _________________County,
State of ________________,
on the _____________ day of _____________
(month) _________________ (year).
________________________________
Applicant Signature
10/2014